Massage Health Intake Form

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To be filled out prior to your scheduled massage appointment.

Name *

Age *

Birthday

YYYY

Gender

Female

Male

Non Binary

Transgender

Clear selection

Pronouns

Occupation

Email *

Address *

Phone number *

Have you ever received a professional massage before?

Yes

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If so, how long ago was your last massage?

Are you currently pregnant? Enter N/A if doesn't apply. If yes how many weeks/which trimester are you in? *

Do you have any specific focus areas you would like to work on in this session? Any goals/expectations? *

Are there any areas you would like to avoid? *

Please indicate Yes or No with working on your Pectoralis Muscles:

Yes

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Please indicate Yes or No with working on your Abdomen:

Yes

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Please indicate Yes or No with working on your Gluteal Muscles:

Yes

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Please list any/all medications (prescribed/over the counter), herbs/plants, homeopathic and vitamin supplements you are currently taking: *

Please list any existing medical conditions to be aware of:

Do you have any allergies? If Yes, please list all allergies: *

Please list all past surgeries (including medical devices and implants): *

Do you have any current or recent injuries to report? If YES, please state the onset of said injury and any symptoms you have experienced since said injury(s): *

Have you received any medical treatment/care for said injury(s)?

Yes

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Emergency Contact Information: Name, Phone number & Relationship *

Where did you hear about Solimar Wellbeing? If referred, please provide their name.

COVID 19 Symptoms: Check if Applies

Have you had a fever in the last 24 hours of 100°F or above?

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?

Have you been in contact w/ anyone in the last 14 days diagnosed w/ COVID-19 or had symptoms?

*If you replied 'yes' to any of these questions, please reschedule your appointment *

CONSENT FOR TREATMENT: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly and there shall be no liability on the practitioner’s part should I fail to do so . I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Type Name for Signature & Date for Consent *

If you are having trouble with this form or have questions or concerns, please call/text at: 619 797 6232

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This form was created inside of Solimar Wellness.